Here’s to the future of the NHS

If a trawl through the press cuttings is to be believed, the period of my tenure at the Health Foundation has been a tumultuous one in health policy terms. As I complete my last few days as Chief Executive, I’ve been thinking about the changes over the last decade or so.

My tenure began with Tony Blair’s commitment to much higher spending in return for market orientated reform and ended, in England at least, with even more radical pro-market reform in return for flat growth in spending. The NHS saw organisational change in all four UK countries, despite politicians’ repeated statements about there being no appetite for reorganisation. In England, in particular, we saw continual commissioning churn – just as one set of commissioners got to grips with the task, they were abolished or merged, bringing new, less experienced players into that role.

For me the outcome of all of this is a perverse one. Despite political devolution and English ministerial initiatives such as Milburn’s ‘Shifting the Balance of Power’, we now have an NHS that is more centrally controlled with far less local autonomy for local decision making than was the case at the start of the millennium. As the biggest of the devolved budgets, it was inevitable that there would be this level of intense interest in the NHS as new parliaments and assemblies flexed their muscles.

In England meanwhile, driven by a fear of the so-called ‘postcode lottery’ of care, local commissioning bodies that had been largely free to set their own priorities within a national framework, increasingly found themselves beholden to their strategic health authorities that were, in turn, just local arms of the Department of Health. Hospitals were also increasingly accountable to the tier above and the rush to foundation status was, ironically, their attempt to regain recently lost autonomy.

In a sense, does any of this matter?

In very many ways it doesn’t. Much more important in terms of the quality of services on the ground, were the dramatic improvements in the delivery of cancer care achieved via the cancer networks; in stroke care via the reorganisation of services in London and elsewhere; and in the treatment of heart disease via better access and improved medical technology. The rise in obesity notwithstanding, we were becoming a healthier, wealthier nation. Waiting lists, so long the scourge of the NHS, were a thing of the past.

Until Chief Medical Officer Liam Donaldson’s seminal report in 2000, An organisation with a memory, it was generally accepted that hospitals were dangerous places, that errors were inevitable and that when they did occur it was largely the fault of one individual. Thereafter, thanks to the Health Foundation’s Safer Patients Initiative and others taking up Donaldson’s challenge, active safety management in hospitals began to be the norm and patients lives saved.

At the same time, inspired by the work of the Institute of Healthcare Improvement and supported by the Modernisation Agency and its equivalent organisations in Wales, Scotland and Northern Ireland, the notion of continuous improvement began to take hold. The many successful Health Foundation Shine and Closing the Gap award holders attest to the remarkable bottom-up groundswell of energy unleashed to improve the quality and safety of care for patients.

And the steady growth in research interest in improvement is also important. By the end of the decade we could realistically begin to speak of the discipline of improvement science, and the Foundation could invest in improvement science fellowships and PhD awards, alongside its well established Clinician Scientist Fellowships.

However, in one important sense the centralising policy churn I began with did really matter. As decision making became increasingly centralised there were unintended negative consequences.

The first was the rise of ‘hit-your-targets-at-all-cost’ management. This established the powerful cultural context within which the unscrupulous could thrive and create the monster that was Mid Staffordshire. Scores of Health Foundation Quality Improvement and GenerationQ Fellows are testament to there being another way, but still the predominant trait of NHS management today is one of 'progress monitoring'. This rebalancing must continue and the choice of the new NHS England CEO will be a crucial test of whether it will in the future.

The second consequence was a form of decision making paralysis caused by ministers’ failure to take the very decisions they were no longer willing to delegate. This has led to 21st century hospital care being delivered in 20th century district general hospital institutions. We are still working to a pattern of secondary care designed by Enoch Powell in the 1960s, frozen in aspic because of a lack of vision and leadership to enact change.

If we are not very careful, the result will be ever larger numbers of small and medium sized district general hospitals getting into both financial difficulty and failing to hit quality targets over the next few years. NHS England must step up to the plate and produce a radical vision for the delivery of hospital care if the NHS is to survive the next few years of financial penury.

But what of the patient in all of this? 

Blair’s NHS Plan of 2000 recommended the abolition of community health councils in England with their successor bodies stripped of status and funding in 2003. Since 1973 they had been the voice of the patient and the public in the NHS but in reality even they had not been able to influence the ‘doctor-knows-best’ culture of NHS care.

Engaging patients became a growing feature of policy rhetoric during the noughties. But policy makers were never clear about what role they expected patients to play and rarely did ministers have the interest or patience to turn their many high sounding initiatives into embedded changes in clinical practice across the service. 

In this era of social media, in all other walks of life the citizen, the consumer, the individual – call us what you will – has become a much more active player. We need to become partners in healthcare too. Yet there is still much work to be done in this area. The NHS Constitution introduced at the tail end of the Brown Administration still lacks visibility and teeth. The NHS Choices website has yet to fulfil its ambition to become the TripAdvisor for healthcare and the ‘friends and family’ test is yet to prove its worth.

So what of the future? If you are a glass half empty person and call yourself a realist you would take what I have just said and see dark clouds ahead for the NHS. Frankly you may be right. But I remain an optimist.

The NHS continues to have the potential to do more than muddle through as it has so often had to do in the past. With the right kind of leadership and political will to make radical changes to the pattern of hospital care, with a relentless focus on keeping patients safe and by unleashing the knowledge and power of the patient, it will thrive. But it will need the Health Foundation alongside it to continue to inspire improvement.

Stephen is retiring as Chief Executive of the Health Foundation on 27 September 2013, www.twitter.com/thornton_health